Cultural Competence in Health or Why Bad Outcomes Happen to Good Patients

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Cultural Competence in Health or Why Bad Outcomes
Happen to Good Patients

• Valda Boyd Ford,
• MPH, MS, RN
• CEO, Center for Human Diversity, Inc.
• Director, Community and Multicultural Affairs
• University of Nebraska Medical Center Community
  Partnership
• 402-559-9660
• vford_at_unmc.edu

www.centerforhumandiversity.org
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Definition

• Cultural Competence is the integration and
  transformation of knowledge about individuals and
  groups of people into specific standards,
  policies, practices, and attitudes used in
  appropriate cultural settings to increase quality
  of services, thereby producing better outcomes
  (Davis and Donald, 1997)

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Culturally and Linguistically Appropriate
Services (CLAS)

• The standards respond to the need to ensure that
  all people entering the health care system
  receive equitable and effective treatment in a
  culturally and linguistically appropriate manner
  and are proposed as a means to correct
  inequities that currently exist in the provision
  of health services and to make these services
  more responsive to the individual needs of all
  patients/consumers.
• They are especially designed to address the
  needs of racial, ethnic, and linguistic
  population groups that experience unequal access
  to health services and ultimately to contribute
  to the elimination of racial and ethnic health
  disparities and to improve the health of all
  Americans.
• http//www.omhrc.gov/clas/frclas2.htm

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More than race and ethnicity

• Xenophobia
• Resentment
• Resistance
• Kennedy and simple justice

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Nine Major Cultural Competency Techniques

• Interpreter services
• Recruitment and retention policies
• Training
• Coordinating with traditional healers
• Use of community health workers,

• Culturally competent health promotion, including
  family and community members
• Immersion into another culture, and
• Administrative and organizational accommodations.

Can Cultural Competency Reduce Racial And Ethnic
Health Disparities? A Review And Conceptual Model
by Cindy Brach and Irene Fraserirector Agency for
Healthcare Research and Quality, 2000
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Why should we bother?

• Three major indicators of a societys health
• Infant Mortality
• Longevity
• Disability
• But we know enough about this.
• Things we dont talk about . . . .

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Psychologists and older adults

• A recent survey of APA-member practicing
  psychologists indicated that the vast majority
  (69) conduct some clinical work with older
  adults, at least occasionally, but that fewer
  than 30 report having had any graduate
  coursework in geropsychology, and fewer than 20
  any supervised practicum or internship experience
  with older adults (Qualls, Segal,
  Norman,Niederehe, Gallagher-Thompson, 2002).
• Many psychologists may be reluctant to work with
  older adults, feeling ill prepared in knowledge
  and skills.
• http//www.apa.org/practice/Guidelines_for_Psychol
  ogical_Practice_with_Older_Adults.pdf

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• Psychologists are encouraged to recognize how
  their attitudes and beliefs about aging and about
  older individuals may be relevant to their
  assessment and treatment of older adults, and to
  seek consultation or further education about
  these issues when indicated.

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• Inaccurate stereotypes of older adults contribute
  to negative biases and affect the delivery of
  psychological services (Abeles et al., 1998
  Rodeheaver, 1990).
• with age inevitably comes senility
• older adults have increased rates of mental
  illness, (depression)
• older adults are inefficient in the workplace
• most older adults are frail and ill
• older adults are socially isolated
• older adults have no interest in sex or intimacy
  
• older adults are inflexible and stubborn
  (Edelstein Kalish, 1999).

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• Such views can become self-fulfilling prophecies,
  leading to misdiagnosis of disorders and
  inappropriately decreased expectations for
  improvement, so-called therapeutic nihilism
  (Goodstein, 1985 Perlick Atkins, 1984 Settin,
  1982), and to the lack of preventive actions and
  treatment (Dupree Paterson, 1985). For example,
  complaints such as anxiety, tremors, fatigue,
  confusion, and irritability may be attributed to
  old age or senility (Goodstein, 1985).

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• Older adults treatable depression w/ lethargy,
  decreased appetite, and lack of interest in
  activities old age.
• Older adults are too old to change (Zarit, 1980),
  wont benefit from psychosocial therapies (Gatz
  Pearson, 1988)
• Discriminatory behavior by health providers
  toward older adults may be linked more to
  provider biases about physical health conditions
  associated with age than to ageism as such (Gatz
  Pearson, 1988 James Haley, 1995).
• Older people themselves can harbor ageist
  attitudes.

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• Some health professionals may avoid serving older
  adults because such work evokes discomfort
  related to their own aging or own relationships
  with parents or other older family members, a
  phenomenon sometimes termed gerophobia
  (Verwoerdt, 1976).

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• Paternalistic attitudes and behavior can
  potentially compromise the therapeutic
  relationship (Horvath Bedi, 2002 Knight, 1996
  Newton Jacobowitz, 1999) and reinforce
  dependency (Baltes, 1996).
• http//www.apa.org/practice/Guidelines_for_Psychol
  ogical_Practice_with_Older_Adults.pdf

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• Positive stereotypes (e.g., the viewpoint that
  older adults are cute, childlike, or
  grandparentlike), which are often overlooked in
  discussions of age-related biases (Edelstein
  Kalish, 1999), can also adversely affect the
  assessment and therapeutic process and outcomes
  (Kimerling, Zeiss, Zeiss, 2000 Zarit, 1980).
  Such biases due to sympathy or the desire to make
  allowances for shortcomings can result in
  inflated estimates of older adults skills or
  mental health and consequent failure to intervene
  appropriately (Braithwaite, 1986).

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Bad Outcomes for

• Seniors
• People with disabilities
• New immigrants and refugees
• People who do not speak English as a first
  language
• GLBT
• Obese

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Stacking Effect

• Take any health condition
• Add poverty
• Add illiteracy
• Add disability
• Add non-white . . .
• And the outcome is BADDDDDDDD

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How to help

• Self-assessment
• Organizational assessment
• Policies and procedures that anticipate the needs
  of the most vulnerable
• Continuing education about the benefits of
  cultural competence
• Decreasing fear about losing something when
  helping others

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Cultural Competence

• Unconsciously incompetent
• Consciously incompetent
• Consciously competent
• Unconsciously competent
• Larry Purnell - 2000